Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff

<p>Abstract</p> <p>Background</p> <p>In the UK, audiology services deliver the majority of tinnitus patient care, but not all patients experience the same level of service. In 2009, the Department of Health released a Good Practice Guide to inform commissioners about key aspects of a quality tinnitus service in order to promote equity of tinnitus patient care in UK primary care, audiology, and in specialist multi-disciplinary centres. The purpose of the present research was to evaluate utilisation and opinions on pathways for the referral of tinnitus patients to and from English Audiology Departments.</p> <p>Methods</p> <p>We surveyed all audiology staff engaged in providing tinnitus services across England. A 36-item questionnaire was mailed to 351 clinicians in all 163 National Health Service (NHS) Trusts identified as having a tinnitus service. 138 clinicians responded. The results presented here describe experiences and opinions of the current patient pathways to and from the audiology tinnitus service.</p> <p>Results</p> <p>The most common referral pathway was from general practice to a hospital-based Ear, Nose & Throat department and from there to a hospital-based audiology department (64%). Respondents considered the NHS tinnitus referral process to be generally effective (67%), but expressed needs for improving GP referral and patients' access to services. 'Open access' to the audiology clinic was rarely an option for patients (9%), nor was the opportunity to access specialist counselling provided by clinical psychology (35%). To decrease the number of inappropriate referrals, 40% of respondents called for greater awareness by referrers about the audiology tinnitus service.</p> <p>Conclusions</p> <p>Respondents in the present survey were generally satisfied with the tinnitus referral system. However, they highlighted some potential targets for service improvement including 1] faster and more appropriate referral from GPs, to be achieved through education on tinnitus referral criteria, 2] improved access to psychological services through audiologist training, and 3] ongoing support from tinnitus support groups, national charities, or open access to the tinnitus clinic for existing patients.</p

Association of Dietary Factors with Presence and Severity of Tinnitus in a Middle-Aged UK Population

Objective The impact of dietary factors on tinnitus has received limited research attention, despite being a considerable concern among people with tinnitus and clinicians. The objective was to examine the link between dietary factors and presence and severity of tinnitus. Design This study used the UK Biobank resource, a large cross-sectional study of adults aged 40–69. 171,722 eligible participants were asked questions specific to tinnitus (defined as noises such as ringing or buzzing in the head or ears). Dietary factors included portions of fruit and vegetables per day, weekly fish consumption (oily and non-oily), bread type, cups of caffeinated coffee per day, and avoidance of dairy, eggs, wheat and sugar. We controlled for lifestyle, noise exposure, hearing, personality and comorbidity factors. Results Persistent tinnitus, defined as present at least a lot of the time, was elevated with increased: (i) fruit/vegetable intake (OR = 1.01 per portion/day), (ii) bread (wholemeal/wholegrain, OR = 1.07; other bread, 1.20) and (iii) dairy avoidance (OR = 1.27). Persistent tinnitus was reduced with: (i) fish consumption (non-oily, OR = 0.91; oily, 0.95), (ii) egg avoidance (OR = 0.87) and (iii) caffeinated coffee consumption (OR = 0.99 per cup/day). Reports of “bothersome” tinnitus (moderate-severe handicap) increased with wholemeal/wholegrain bread intake (OR = 0.86). Reports of less frequent transient tinnitus increased with dairy avoidance (OR = 1.18) and decreased with caffeinated coffee (OR = 0.98 per cup/day) and brown bread (OR = 0.94). Conclusions This is the first population study to report the association between dietary factors and tinnitus. Although individually dietary associations are mostly modest, particular changes in diet, such as switching between foodstuffs, may result in stronger associations. These findings offer insights into possible dietary associations with tinnitus, and this may be useful when discussing management options in combination with other lifestyle changes and therapies

In-situ observations of young contrails – overview and selected results from the CONCERT campaign

Lineshaped contrails were detected with the research aircraft Falcon during the CONCERT – CONtrail and Cirrus ExpeRimenT – campaign in October/November 2008. The Falcon was equipped with a set of instruments to measure the particle size distribution, shape, extinction and chemical composition as well as trace gas mixing ratios of sulfur dioxide (SO&lt;sub&gt;2&lt;/sub&gt;), reactive nitrogen and halogen species (NO, NO&lt;sub&gt;y&lt;/sub&gt;, HNO&lt;sub&gt;3&lt;/sub&gt;, HONO, HCl), ozone (O&lt;sub&gt;3&lt;/sub&gt;) and carbon monoxide (CO). During 12 mission flights over Europe, numerous contrails, cirrus clouds and a volcanic aerosol layer were probed at altitudes between 8.5 and 11.6 km and at temperatures above 213 K. 22 contrails from 11 different aircraft were observed near and below ice saturation. The observed NO mixing ratios, ice crystal and soot number densities are compared to a process based contrail model. On 19 November 2008 the contrail from a CRJ-2 aircraft was penetrated in 10.1 km altitude at a temperature of 221 K. The contrail had mean ice crystal number densities of 125 cm&lt;sup&gt;−3&lt;/sup&gt; with effective radii &lt;i&gt;r&lt;/i&gt;&lt;sub&gt;eff&lt;/sub&gt; of 2.6 μm. The presence of particles with &lt;i&gt;r&lt;/i&gt;&gt;50 μm in the less than 2 min old contrail suggests that natural cirrus crystals were entrained in the contrail. Mean HONO/NO (HONO/NO&lt;sub&gt;y&lt;/sub&gt;) ratios of 0.037 (0.024) and the fuel sulfur conversion efficiency to H&lt;sub&gt;2&lt;/sub&gt;SO&lt;sub&gt;4&lt;/sub&gt; (&amp;epsilon;&lt;sub&gt;&lt;i&gt;S&lt;/i&gt;↓&lt;/sub&gt;) of 2.9 % observed in the CRJ-2 contrail are in the range of previous measurements in the gaseous aircraft exhaust. On 31 October 2010 aviation NO emissions could have contributed by more than 40% to the regional scale NO levels in the mid-latitude lowest stratosphere. The CONCERT observations help to better quantify the climate impact from contrails and will be used to investigate the chemical processing of trace gases on contrails

Ice particle sampling from aircraft – influence of the probing position on the ice water content

The ice water content (IWC) of cirrus clouds is an essential parameter determining their radiative properties and thus is important for climate simulations. Therefore, for a reliable measurement of IWC on board research aircraft, it is important to carefully design the ice crystal sampling and measuring devices. During the ML-CIRRUS field campaign in 2014 with the German Gulfstream GV HALO (High Altitude and Long Range Research Aircraft), IWC was recorded by three closed-path total water together with one gas-phase water instrument. The hygrometers were supplied by inlets mounted on the roof of the aircraft fuselage. Simultaneously, the IWC is determined by a cloud particle spectrometer attached under an aircraft wing. Two more examples of simultaneous IWC measurements by hygrometers and cloud spectrometers are presented, but the inlets of the hygrometers were mounted at the fuselage side (M-55 Geophysica, StratoClim campaign 2017) and bottom (NASA WB57, MacPex campaign 2011). This combination of instruments and inlet positions provides the opportunity to experimentally study the influence of the ice particle sampling position on the IWC with the approach of comparative measurements. As expected from theory and shown by computational fluid dynamics (CFD) calculations, we found that the IWCs provided by the roof inlets deviate from those measured under the aircraft wing. As a result of the inlet position in the shadow zone behind the aircraft cockpit, ice particle populations with mean mass sizes larger than about 25 µm radius are subject to losses, which lead to strongly underestimated IWCs. On the other hand, cloud populations with mean mass sizes smaller than about 12 µm are dominated by particle enrichment and thus overestimated IWCs. In the range of mean mass sizes between 12 and 25 µm, both enrichment and losses of ice crystals can occur, depending on whether the ice crystal mass peak of the size distribution – in these cases bimodal – is on the smaller or larger mass mode. The resulting deviations of the IWC reach factors of up to 10 or even more for losses as well as for enrichment. Since the mean mass size of ice crystals increases with temperature, losses are more pronounced at higher temperatures, while at lower temperatures IWC is more affected by enrichment. In contrast, in the cases where the hygrometer inlets were mounted at the fuselage side or bottom, the agreement of IWCs is most frequently within a factor of 2.5 or better – due to less disturbed ice particle sampling, as expected from theory – independently of the mean ice crystal sizes. The rather large scatter between IWC measurements reflects, for example, cirrus cloud inhomogeneities and instrument uncertainties as well as slight sampling biases which might also occur on the side or bottom of the fuselage and under the wing. However, this scatter is in the range of other studies and represent the current best possible IWC recording on fast-flying aircraft.</p

Self evaluation of communication experiences after laryngeal cancer – A longitudinal questionnaire study in patients with laryngeal cancer

<p>Abstract</p> <p>Background</p> <p>Aim of this longitudinal study was to investigate the sensitivity to change of the Swedish Self Evaluation of Communication Experiences after Laryngeal Cancer questionnaire (the S-SECEL), addressing communication dysfunction in patients treated for laryngeal cancer. Previous studies have highlighted the need for more specific questionnaires for this purpose.</p> <p>Methods</p> <p>100 patients with Tis-T4 laryngeal cancer were included prior to treatment onset. Patients answered four questionnaires at six occasions during one year; the S-SECEL, the European Organisation for Research and Treatment of Cancer (EORTC) Core Quality of Life Core Questionnaire (QLQ-C30) supplemented by the Head and Neck cancer module (QLQ-H&N35) and the Hospital Anxiety and Depression (HAD) scale. In addition, performance status was assessed. Differences within groups were tested with the Wilcoxon paired signed ranks test and between-group analyses were carried out using the Mann-Whitney <it>U </it>test. Magnitude of group differences was analyzed by means of effect sizes.</p> <p>Results</p> <p>The S-SECEL was well accepted with a response rate of 76%. Communication dysfunction increased at 1 month, followed by a continuous decrease throughout the year. Changes were statistically significant at most measurement, demonstrating the sensitivity of the S-SECEL to changes in communication over time. The S-SECEL and the EORTC QLQ-C30 with the QLQ-H&N35 demonstrated similar results; however the S-SECEL was more sensitive regarding communication dysfunction. The largest changes were found in the most diagnose specific items concerning voice and speech.</p> <p>Conclusion</p> <p>The S-SECEL was investigated in the largest Scandinavian longitudinal study concerning health-related quality of life (HRQL) in laryngeal cancer patients. The questionnaire was responsive to change and showed convergent results when compared to established HRQL questionnaires. Our findings also indicate that the S-SECEL could be a more suitable instrument than the EORTC QLQ-C30 with QLQ-H&N35 when measuring communication experiences in patients with laryngeal cancer; it is more sensitive, shorter and can be used on an individual basis. As a routine screening instrument the S-SECEL could be a valuable tool for identifying patients at risk for psychosocial problems and to help plan rehabilitation. It is therefore recommended for clinical use in evaluation of communication dysfunction for all patients with laryngeal cancer irrespective of treatment.</p

Tropopause and hygropause variability over the equatorial Indian Ocean during February and March 1999.

Measurements of temperature, water vapor, total water, ozone, and cloud properties were made above the western equatorial Indian Ocean in February and March 1999. The cold-point tropopause was at a mean pressure-altitude of 17 km, equivalent to a potential temperature of 380 K, and had a mean temperature of 190 K. Total water mixing ratios at the hygropause varied between 1.4 and 4.1 ppmv. The mean saturation water vapor mixing ratio at the cold point was 3.0 ppmv. This does not accurately represent the mean of the measured total water mixing ratios because the air was unsaturated at the cold point for about 40% of the measurements. As well as unsaturation at the cold point, saturation was observed above the cold point on almost 30% of the profiles. In such profiles the air was saturated with respect to water ice but was free of clouds (i.e., backscatter ratio <2) at potential temperatures more than 5 K above the tropopause and hygropause. Individual profiles show a great deal of variability in the potential temperatures of the cold point and hygropause. We attribute this to short timescale and space-scale perturbations superimposed on the seasonal cycle. There is neither a clear and consistent “setting” of the tropopause and hygropause to the same altitude by dehydration processes nor a clear and consistent separation of tropopause and hygropause by the Brewer-Dobson circulation. Similarly, neither the tropopause nor the hygropause provides a location where conditions consistently approach those implied by a simple “tropopause freeze drying” or “stratospheric fountain” hypothesis

Tinnitus: Distinguishing between Subjectively Perceived Loudness and Tinnitus-Related Distress

OBJECTIVES: Overall success of current tinnitus therapies is low, which may be due to the heterogeneity of tinnitus patients. Therefore, subclassification of tinnitus patients is expected to improve therapeutic allocation, which, in turn, is hoped to improve therapeutic success for the individual patient. The present study aims to define factors that differentially influence subjectively perceived tinnitus loudness and tinnitus-related distress. METHODS: In a questionnaire-based cross-sectional survey, the data of 4705 individuals with tinnitus were analyzed. The self-report questionnaire contained items about subjective tinnitus loudness, type of onset, awareness and localization of the tinnitus, hearing impairment, chronic comorbidities, sleep quality, and psychometrically validated questionnaires addressing tinnitus-related distress, depressivity, anxiety, and somatic symptom severity. In a binary step-wise logistic regression model, we tested the predictive power of these variables on subjective tinnitus loudness and tinnitus-related distress. RESULTS: The present data contribute to the distinction between subjective tinnitus loudness and tinnitus-related distress. Whereas subjective loudness was associated with permanent awareness and binaural localization of the tinnitus, tinnitus-related distress was associated with depressivity, anxiety, and somatic symptom severity. CONCLUSIONS: Subjective tinnitus loudness and the potential presence of severe depressivity, anxiety, and somatic symptom severity should be assessed separately from tinnitus-related distress. If loud tinnitus is the major complaint together with mild or moderate tinnitus-related distress, therapies should focus on auditory perception. If levels of depressivity, anxiety or somatic symptom severity are severe, therapies and further diagnosis should focus on these symptoms at first

Aircraft-based observations of isoprene-epoxydiol-derived secondary organic aerosol (IEPOX-SOA) in the tropical upper troposphere over the Amazon region

During the ACRIDICON-CHUVA field project (September-October 2014;based in Manaus, Brazil) aircraft-based in situ measurements of aerosol chemical composition were conducted in the tropical troposphere over the Amazon using the High Altitude and Long Range Research Aircraft (HALO), covering altitudes from the boundary layer (BL) height up to 14.4 km. The submicron non-refractory aerosol was characterized by flash-vaporization/electron impact-ionization aerosol particle mass spectrometry. The results show that significant secondary organic aerosol (SOA) formation by isoprene oxidation products occurs in the upper troposphere (UT), leading to increased organic aerosol mass concentrations above 10 km altitude. The median organic mass concentrations in the UT above 10 km range between 1.0 and 2.5 mu g m(-3) (referring to standard temperature and pressure;STP) with interquartile ranges of 0.6 to 3.2 mu g m(-3) (STP), representing 78 % of the total submicron non-refractory aerosol particle mass. The presence of isoprene-epoxydiol-derived secondary organic aerosol (IEPOX-SOA) was confirmed by marker peaks in the mass spectra. We estimate the contribution of IEPOX-SOA to the total organic aerosol in the UT to be about 20 %. After isoprene emission from vegetation, oxidation processes occur at low altitudes and/or during transport to higher altitudes, which may lead to the formation of IEPOX (one oxidation product of isoprene). Reactive uptake or condensation of IEPOX on preexisting particles leads to IEPDX-SOA formation and subsequently increasing organic mass in the UT. This organic mass increase was accompanied by an increase in the nitrate mass concentrations, most likely due to NOx production by lightning. Analysis of the ion ratio of NO+ to NO2+ indicated that nitrate in the UT exists mainly in the form of organic nitrate. IEPOX-SOA and organic nitrates are coincident with each other, indicating that IEPDX-SOA forms in the UT either on acidic nitrate particles forming organic nitrates derived from IEPDX or on already neutralized organic nitrate aerosol particles